RU2740570C1 - Method for isolated fraction retrograde hepatic perfusion in experiment - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, particularly to surgery, oncology, transplantology. After the corpse liver explantation, the perfusion is determined; followed by ligating a round hepatic ligament, mobilizing a portal vein, its right and left branches, a hepatic artery, its right and left branches, and a retro-hepatic segment of the inferior vena cava with ligature of short liver veins. That is followed by cholecystectomy. That is followed by successively placing the cannula with an outer diameter of 2–4 mm into a branch of the hepatic artery and a cannula of an external diameter of 6–12 mm into a branch portal vein of the perfused portion using vascular tourniquets. Hepatic veins participating in the venous outflow are squeezed at their bases on the side of the perfused part at the side to exclude leakage of the perfusate in the inferior vena cava. Further, the perfusion contour is formed by connecting the inflow systems from the reservoir with the perfusate to the preparation, to the arterial cannulas, outflow - from the liver to the reservoir - to the venous cannulas, the perfusion pump, the thermostatic bath and connectors for connection of the infusion filters, splitters, extensions, tees for the infusion systems. That is followed by performing an isolated retrograde lavage perfusion of the liver in the following: a perfusion direction - an influx onto a branch of the hepatic artery, an outflow from the portal vein branch of the perfusion fraction. Flow rate is 110–650 ml/min, duration is 20–60 min, perfusate temperature is 37–43 °C. Further, during perfusion, a solution of a water-soluble dye with a total volume of 20–50 ml/min is introduced during perfusion in order to determine the inter-lobe border and to control the vascular isolation of the perfusion to be treated. Upon completion of perfusion, the liver preparation is analysed and utilized.

EFFECT: method enables creating a basis for using transplantation technologies in abdominal "ex vivo" surgery, qualitatively isolating the lobes of the liver in order to perform its retrograde selective perfusion with the required preparation solution, as well as does not require additional search for perfusate outflow path and associated increased volume of surgical intervention and anaesthesia.

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Description

The invention relates to medicine, in particular to surgery, oncology, transplantology, and can be used when carrying out techniques associated with the need to isolate the shared vascular blood flow of the liver and its selective perfusion.

Currently, the development of combined treatment methods with the use of regional chemotherapy in patients with multiple bilobar liver lesions remains an urgent problem (S.V. Kozlov et al., Yu.I. Patyutko, 2014). In this regard, methods of high-dose isolated liver chemoperfusion are widely used. (T. Voron et al. 2013, M.S. Burgmans et al. 2015, T.J. Vogl et al., 2017). The main disadvantages of these techniques are: forced block of blood flow in the inferior vena cava (IVC) and the need for the formation of a cava-caval shunt, the high cost of closed techniques and, finally, the leakage of perfusate into the systemic circulation. In addition, there is no information in the available literature about the possibility of performing perfusion techniques associated with vascular isolation of one of the liver lobes or combining them with surgical methods of treatment.

The known method of isolated liver perfusion (method of isolated hyperthermic chemoperfusion of the liver, RF patent No. 2664631, A61P 35/00, A61K 38/36, A61K 38/19, A61B 17/00 publ. 09/21/2018). In this method, the liver is isolated from the systemic blood flow, a perfusion circuit is formed and perfusion of the metastatic liver with an antitumor drug is performed. However, this method does not provide for the possibility of perfusion of individual liver lobes, and therefore, in some cases, the possibilities of its use are limited.

A method is proposed for isolated lobar retrograde liver perfusion in an experiment, the purpose of which is to perform sequential surgical procedures allowing to isolate the lobar liver blood flow and to carry out its selective perfusion with the necessary pharmaceutical. This method is proposed to be used in oncology, as a chemoregional therapy, as an improved method for treating malignant lesions, or in combination with methods of staged liver resections, so-called "ex vivo" operations, as well as in transplantology.

The problem is solved by the fact that in the method of isolated lobar retrograde liver perfusion in the experiment, after explantation of the cadaveric liver, the fraction for perfusion with the necessary drug is determined (hereinafter referred to as the “perfused lobe”); after which, the round ligament of the liver is ligated, the portal vein (BB), its right (PV), left (PV) branches, its own hepatic artery (SPA), its right (PA) and left (LA) branches and the retrohepatic segment (PC ) IVC with ligation of the short veins of the liver; further, cholecystectomy is performed; then, cannulas with an external diameter of 2 to 4 mm are sequentially installed into the branch of the SPA and cannulas with an external diameter of 6 to 12 mm are inserted into the branch of the IV of the perfused lobe using vascular turnstiles; after that, on the side of the perfused lobe, the hepatic veins participating in the venous outflow are squeezed from their bases to prevent leakage of the perfusate into the IVC; further, a perfusion circuit is formed by connecting the inflow systems (from the reservoir with the perfusate to the drug) to the arterial cannulas, the outflow (from the drug to the reservoir) to the venous cannulas, the circuit also includes a reservoir with a solution for perfusion, a reservoir for collecting the spent perfusate at the outlet from the circuit (in cases of the formation of an open circuit), a perfusion pump, a thermostatic bath and connectors (for connecting infusion filters, splitters, extension cords, tees for infusion systems); after that, isolated retrograde lobe perfusion of the liver is performed in the following mode: direction of perfusion - inflow to the branch of the SPA, outflow from the IV branch of the perfused lobe; flow rate - 110-650 ml / min, duration - 20-60 min, perfusate temperature -37-43 ° С; then, during perfusion, in order to determine the interlobar boundary and control the vascular isolation of the perfused lobe, solutions of various water-soluble dyes (for example: 0.05% brilliant green, 1% blue, 0.4% basic fuchsin, etc.) are injected with a total volume of 20 -50 ml / min; upon completion of the perfusion, the liver specimen is examined and disposed of in accordance with the requirements of the guidelines.

The technical characteristics of the cannulas, as well as the composition of the contour, the injected solution and the perfusion parameters, are determined depending on the actual requirements and the optimal ones are selected.

The presented values of the diameter of the vascular cannulas are determined by the need to maintain proper velocity parameters, and cannot be larger than the diameter of the vessels used. Since it is difficult to create adequate hydrodynamic conditions on cadaveric tissue, the higher the diameter of the venous cannula installed in the IV branch, the more efficient is the outflow of perfusate from the liver and, therefore, the less resistance to the flow of perfusate in the vascular bed of the perfused lobe. In this regard, the diameter of the cannulas in the branches of the SPA (4-6 mm) is always larger than that of the cannulas installed in the BB branches (6-12 mm). When using cannulas with a smaller diameter, it is difficult to perform perfusion on a liver specimen.

The rate parameters of perfusion were as close as possible to physiological ones. However, their amendment was made taking into account the work on cadaveric tissue. Thus, at a rate of less than 110 ml / min, the efficiency of perfusion decreased, as evidenced by the nature of the spread of perfusate along the vascular bed. An increase in the perfusate flow rate above 650 ml / min led to damage to the parenchyma of the cadaveric liver, which affected the quality of the study. The duration of perfusion and hyperthermia in the experiment was determined in accordance with the requirements of clinical practice.

The volume of the injected solution of a water-soluble dye from 20 to 50 ml / min was determined by the rate of perfusion and the morphometric characteristics of the drug. However, the introduction of a smaller volume reduced the information content of the study, which was expressed in a weak staining of the vascular bed. The introduction of a larger volume, according to our data, is not economically feasible.

The use of this method makes it possible to qualitatively isolate the lobar blood flow of the liver in order to carry out its retrograde selective perfusion with a solution of the required drug. The main advantage of the method is its ease of use, since it does not require additional search for ways of perfusate outflow and the associated increase in the volume of surgical intervention and anesthetic benefits. Almost the entire volume of the operative stage is carried out at the gate of the liver, without the need to form a cava-caval shunt. From the point of view of anatomical and physiological features, the perfusate tends to follow the path of least resistance, which explains the free arterio-portal flow of the perfusate when blocking blood flow through the hepatic veins. At the same time, this leads to minimization of the risks of leakage into the contralateral lobe in the presence of intrahepatic arterial messages. The introduction of this method into clinical practice will improve the previous and propose new methods of combined treatment of multiple bilobar liver lesions, as well as create a basis for the use of transplant technologies in abdominal, including "ex vivo" surgery.

The invention is illustrated in FIG. 1, which shows a schematic diagram of a perfusion circuit for performing isolated lobar retrograde liver perfusion in an experiment, and provides experimental examples, which are illustrated in FIG. 1, fig. 2, fig. 3, fig. 4.

FIG. Figure 2 demonstrates the procedure for installing vascular cannulas, their fixation and the nature of the distribution of the dye after isolated retrograde perfusion of the left lobe. FIG. 3 shows the appearance of the drug from the side of its diaphragmatic surface after isolated retrograde perfusion of the left lobe. FIG. 4 shows a preparation subjected to anatomical examination after isolated retrograde perfusion of the right lobe of the liver.

As shown in FIG. 1, first perform preparation for perfusion of the liver preparation 5. Next, form a perfusion circuit by attaching the inflow systems to the cannula installed in the SPA branch, and outflow systems to the cannula installed in the IV branch of the perfused lobe — dotted lines with arrows. The circuit also includes a reservoir with perfusate 1. A thermostatic bath is installed in the direction of the solution inflow to the perfused portion. The movement of the perfusate in the circuit creates a peristaltic (centrifugal) pump 3, the direction of flow is indicated by arrows. If necessary, injections of drugs are performed through connectors 4. In order to control the temperature of the perfused lobe, thermometry is performed 6.

Example No. 1 - isolated retrograde perfusion of the left lobe of the liver. FIG. 1, fig. 2, fig. 3.

Liver specimen No. 15 was explanted from the unbalanced corpse of patient R., who died from a disease not directly related to the organ under study.

At the first stage, after preliminary preparation of the preparation, the necessary vascular formations (IVC, IV, SPA, their branches) were mobilized, the round ligament was clamped and the short liver veins were ligated. Thereafter, the arterial cannula 7 in FIG. 2 in LA and venous cannula 8 in Fig. 2 in PV (arterial 6 Fr, venous cannula 12 Fr Maquet, Germany) with fixation with vascular straps. To exclude the leakage of perfusate into the IVC from the vascular bed of the left lobe during perfusion, the base of the common trunk of the left, middle hepatic veins was mobilized and clamped.

In a second step, a closed perfusion circuit was formed as shown in FIG. 1, which included the reservoir of perfusate 1 in FIG. 1, thermostatic bath 2 in FIG. 1., peristaltic pump "LOIP ls-301" (manufactured by JSC "Laboratory equipment and devices", Russia) 3 in Fig. 1 purchased with the support of the Government of St. Petersburg (diploma PSP No. 18787) and injection connectors 4 in FIG. 1. Control of the temperature rise was assessed at the beginning and at the end of perfusion using a contact thermometer 6 in FIG. one.

The third step was a retrograde isolated perfusion of the left lobe of the liver 10 in FIG. 2, fig. 3 in the following mode: flow rate - 230 ml / min, duration - 34 min, perfusate temperature - 41 ° С. During perfusion, in order to determine the interlobar boundary and control the leakage of perfusate into the right lobe of the liver 11 in FIG. 2, fig. 3 into the arterial cannula 7 in FIG. 2 via the injection connector 4 in FIG. 1 was injected with 20 ml / min of 1% solution of mytilene blue, as a result of which the interlobar border of the liver was determined - the dotted line bounded by triangles in Fig. 3, which passed at a distance of 4-12 cm from the crescent and round ligaments of the liver 12 in FIG. 3, in the projection of a line running from the right edge of the IVC notch to the right edge of the gallbladder bed, the projection of which is shown P in Fig. 2, fig. 3. On the visceral surface of the liver, the revealed interlobar border passed along the dorsal part of the first segment of the liver 9 in FIG. 2, directly along the middle part of the liver gate itself and along the left edge of the gallbladder bed, the projection of which P in Fig. 2, 3. During the procedure, the perfusate entered the arterial bed through cannula 7 in FIG. 2 and was removed without hindrance through the cannula installed in the PV 8 in FIG. 2. No dye leakage into the IVC lumen and into the contralateral lobe, provided there was a positive hydrodynamic pressure in the perfused lobe. At the end of perfusion, when performing comparative thermometry, there was a significant difference in indicators between the right (perfused) and left lobes of the liver.

Further, using a monopolar electrocoagulator, the gallbladder was removed, the projection of which is indicated by P in Fig. 2, fig. 3.

At the end of the perfusion, the preparation was subjected to anatomical examination, which showed the spread of the dye only within the left lobe of the liver 10 in FIG. 2, fig. 3.

Example No. 2 - isolated retrograde perfusion of the right lobe of the liver. FIG. 1, fig. 4.

Liver specimen No. 27 was explanted from the unbalanced corpse of patient K., who died from a disease not directly related to the organ under study.

At the first stage, after preliminary preparation of the preparation, the necessary vascular formations (IVC, IV, SPA, their branches) were mobilized, the round ligament and short liver veins were ligated. After that, an arterial cannula was sequentially installed in the PA and a venous cannula in the PT (arterial 6 Fr, venous cannula 12 Fr Maquet, Germany) with fixation with vascular ties. To exclude the leakage of perfusate into the IVC from the vascular bed of the right lobe during perfusion, the base of the middle and right hepatic veins was mobilized and clamped.

In a second step, a closed perfusion circuit was formed as shown in FIG. 1, which included the reservoir of perfusate 1 in FIG. 1, thermostatic bath 2 in FIG. 1., peristaltic pump "LOIP ls-301" (manufactured by JSC "Laboratory equipment and devices", Russia) 3 in Fig. 1 purchased with the support of the Government of St. Petersburg (diploma PSP No. 18787) and injection connectors 4 in FIG. 1. Control of the temperature rise was assessed at the beginning and at the end of perfusion using a contact thermometer 6 in FIG. one.

The third step was a retrograde isolated perfusion of the right lobe of the liver 11 in FIG. 4 in the following mode: flow rate - 320 ml / min, duration - 20 min, perfusate temperature - 37 ° С. During perfusion, in order to determine the interlobar boundary and control the leakage of perfusate into the right lobe of the liver 11 in FIG. 4 into the arterial cannula via the injection connector 4 in FIG. 1 was injected with 20 ml / min of 1% solution of mytilene blue, as a result of which the interlobar border of the liver was determined - the dotted line bounded by triangles in Fig. 4, which passed at a distance of 2-9.5 cm from the sickle and round ligaments of the liver 12 in FIG. 4, in the projection of the line running from the left edge of the IVC notch to the middle of the gallbladder bed, the projection of which is shown in Fig. 4. During the procedure, the perfusate entered through the arterial cannula installed in the PA, and was freely discharged through the cannula installed in the PT. No dye leakage into the IVC lumen and into the contralateral lobe, provided there was a positive hydrodynamic pressure in the perfused lobe, was not observed. At the end of perfusion, when performing thermometry, there was a significant difference in parameters between the right (perfused) and left lobes of the liver.

Further, using a monopolar electrocoagulator, the gallbladder was removed, the projection of which is indicated by P in Fig. 4. At the end of the perfusion, the preparation was subjected to anatomical examination, which showed the spread of the dye within the right lobe of the liver 11 in FIG. 4 and its absence in the contralateral -left lobe 10 in FIG. 4.

Claims (1)

The method of isolated lobar retrograde liver perfusion in the experiment, characterized in that after explantation of the cadaveric liver, the perfused lobe is determined; after which the round ligament of the liver is ligated, the portal vein, its right and left branches, its own hepatic artery, its right and left branches, and the retrohepatic segment of the inferior vena cava with ligation of the short veins of the liver are mobilized; then cholecystectomy is performed; then cannulas with an external diameter of 2 to 4 mm are sequentially installed into the branch of the own hepatic artery and cannulas with an external diameter of 6 to 12 mm are inserted into the branch of the portal vein of the perfused lobe using vascular turnstiles; after that, on the side of the perfused lobe, the hepatic veins participating in the venous outflow are squeezed from their bases to prevent leakage of perfusate in the inferior vena cava; then a perfusion circuit is formed by connecting the inflow systems from the reservoir with the perfusate to the drug, to the arterial cannulas, the outflow from the liver to the reservoir - to the venous cannulas, a perfusion pump, a thermostatic bath and connectors for connecting infusion filters, splitters, extension cords, tees for infusion systems ; after that, isolated retrograde lobe perfusion of the liver is performed in the following mode: direction of perfusion - inflow to the branch of its own hepatic artery, outflow from the branch of the portal vein of the perfused lobe; flow rate - 110-650 ml / min, duration - 20-60 min, perfusate temperature - 37-43 ° С; then, during perfusion, in order to determine the interlobar boundary and control the vascular isolation of the perfused lobe, a solution of a water-soluble dye with a total volume of 20-50 ml / min is introduced; upon completion of the perfusion, the liver preparation is examined and disposed of.

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